Facility WatchInspection records for every certified US nursing home
Tigard Rehabilitation and Care
14145 SW 105th Avenue Tigard, OR 97224 (503) 639-1144
CCN
385272
Certified beds
112
Ownership
For profit - Limited Liability company
Chain
Sapphire Health Services
Nurse staffing
6.21
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.51 hours per resident per day
Nursing staff turnover: 100% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected November 17, 2025
3 citations · from a complaint investigation · Health
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected December 17, 2025
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected December 17, 2025
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Past Non-Compliance · corrected April 1, 2025
Inspected July 18, 2025
1 citation · from a complaint investigation · Health
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected August 20, 2025
Inspected January 17, 2025
7 citations · from a complaint investigation · Health
D
F0552No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are fully informed and understand their health status, care and treatments.
Deficient, Provider has date of correction · corrected March 3, 2025
D
F0576No actual harm with potential for more than minimal harm · Isolated
Ensure residents have reasonable access to and privacy in their use of communication methods.
Deficient, Provider has date of correction · corrected March 3, 2025
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected March 3, 2025
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected March 3, 2025
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected March 3, 2025
D
F0730No actual harm with potential for more than minimal harm · Isolated
Observe each nurse aide's job performance and give regular training.
Deficient, Provider has date of correction · corrected March 3, 2025
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected March 3, 2025
Inspected October 10, 2024
1 citation · from a complaint investigation · Health
D
F0557No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Deficient, Provider has date of correction · corrected November 5, 2024
Inspected May 3, 2024
1 citation · from a complaint investigation · Health
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected June 4, 2024
Inspected April 11, 2024
1 citation · from a complaint investigation · Health
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected May 14, 2024
Inspected December 11, 2023
2 citations · from a complaint investigation · Health
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected January 16, 2024
D
F0740No actual harm with potential for more than minimal harm · Isolated
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Deficient, Provider has date of correction · corrected January 16, 2024
Inspected August 11, 2023
15 citations · from a complaint investigation · Health
D
F0553No actual harm with potential for more than minimal harm · Isolated
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Deficient, Provider has date of correction · corrected September 19, 2023
D
F0578No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Deficient, Provider has date of correction · corrected September 19, 2023
D
F0582No actual harm with potential for more than minimal harm · Isolated
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Deficient, Provider has date of correction · corrected September 19, 2023
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected September 19, 2023
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected September 19, 2023
D
F0842No actual harm with potential for more than minimal harm · Isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected September 19, 2023
E
F0584No actual harm with potential for more than minimal harm · Pattern
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Deficient, Provider has date of correction · corrected September 19, 2023
E
F0759No actual harm with potential for more than minimal harm · Pattern
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected September 19, 2023
E
F0804No actual harm with potential for more than minimal harm · Pattern
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected September 19, 2023
E
F0814No actual harm with potential for more than minimal harm · Pattern
Dispose of garbage and refuse properly.
Deficient, Provider has date of correction · corrected September 19, 2023
E
F0947No actual harm with potential for more than minimal harm · Pattern
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Deficient, Provider has date of correction · corrected September 19, 2023
F
F0730No actual harm with potential for more than minimal harm · Widespread
Observe each nurse aide's job performance and give regular training.
Deficient, Provider has date of correction · corrected September 19, 2023
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected September 19, 2023
F
F0868No actual harm with potential for more than minimal harm · Widespread
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Deficient, Provider has date of correction · corrected September 19, 2023
F
F0880No actual harm with potential for more than minimal harm · Widespread
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected September 19, 2023
Inspected June 16, 2022
12 citations · Health
D
F0552No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are fully informed and understand their health status, care and treatments.
Deficient, Provider has date of correction · corrected July 28, 2022
D
F0578No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Deficient, Provider has date of correction · corrected July 28, 2022
D
F0655No actual harm with potential for more than minimal harm · Isolated
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Deficient, Provider has date of correction · corrected July 28, 2022
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected July 28, 2022
D
F0679No actual harm with potential for more than minimal harm · Isolated
Provide activities to meet all resident's needs.
Deficient, Provider has date of correction · corrected July 28, 2022
D
F0759No actual harm with potential for more than minimal harm · Isolated
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected July 28, 2022
D
F0883No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected July 28, 2022
D
F0887No actual harm with potential for more than minimal harm · Isolated
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Deficient, Provider has date of correction · corrected July 28, 2022
E
F0684No actual harm with potential for more than minimal harm · Pattern
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected July 28, 2022
F
F0726No actual harm with potential for more than minimal harm · Widespread
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Deficient, Provider has date of correction · corrected July 28, 2022
F
F0730No actual harm with potential for more than minimal harm · Widespread
Observe each nurse aide's job performance and give regular training.
Deficient, Provider has date of correction · corrected July 28, 2022
K
F0880Immediate jeopardy to resident health or safety · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected July 28, 2022
Penalties
Date
Type
Amount
April 18, 2025
Fine
$35,714
Ownership transfers
Effective
Seller
Buyer
09/01/2023
Pacific Gardens Estates LLC
Sapphire at Tigard Rehab LLC
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.